More and more children are coming to the emergency department (ED) with mental health concerns. Many clinicians have noticed that these children often wait longer—especially if they require admission. But while this is a common observation on the shop floor, we still don’t have strong data to show just how much longer children with mental health needs are staying in the ED compared to those with physical health problems.
What is boarding?
Boarding is the amount of time a patient stays in the emergency department after admission to the hospital.
What other studies found?
Boarding of children in the emergency department (ED) has been described in the literature; however, most available data originate from the United States. These studies often focus on mental health presentations—looking at how often children attend, how frequently they re-attend, and how long they stay.
However, very few have directly compared mental health presentations to non-mental health ones. Some research has explored the reasons why boarding times might be longer for children with mental health needs. Possible explanations include limited community mental health services, a shortage of inpatient beds, and the perception that mental health issues are less acutely urgent.
Why is this important?
Clinicians need evidence to advocate for changes that could lessen the time children remain boarding in emergency departments with mental health concerns.
Chisholm et al. set out to provide quantifiable insights into psychiatric boarding by comparing psychiatric patients to non-psychiatric patients.
Chisholm C, Wang X, Guild K, Lategan C, Hsu Z, Lang E. No room at the inn: pediatric psychiatric patients wait far longer for inpatient beds than their non-psychiatric counterparts; evidence of structural stigma. Can J Emerg Med [Internet]. 2025
Who were the patients?
The study looked at children aged 6 to 17 years who were admitted to hospital from the emergency department between September 2018 and September 2023. Children who visited the ED but were not admitted were excluded from the analysis.
Each child’s diagnosis was used to place them into one of two groups: those with a psychiatric presentation and those with a non-psychiatric (physical health) presentation.
The outcomes of the study
Primary outcome
The primary goal of the study was to determine and compare the boarding time between children admitted for psychiatric conditions and those without psychiatric conditions.
Secondary outcomes
The primary aim was to compare the duration of stay in the ED for children in each group. The researchers looked at two things:
Time to be seen by a doctor – how long it took for each child to be seen by a clinician after arriving.
ED length of stay – how long each child remained in the emergency department, from arrival to departure.
Results
Over the five-year study period, a total of 38,821 children were admitted from the emergency department.
Among those with psychiatric presentations, the median age was 15 years.
One in four (25%) of these admissions were for mental health or psychiatric concerns.
The remaining 75% were admitted with other medical problems.
Boarding
Children admitted with psychiatric concerns waited 1.6 times longer for a hospital bed than those admitted with physical health problems. This difference in waiting time was consistent across the entire five-year study period.
The longest waits were seen in children who required transfer to an inpatient psychiatric unit — highlighting the challenges in accessing appropriate mental health beds.
ED length of stay and initial physician assessment
Children with mental health concerns didn’t just wait longer for a bed – they also spent more time in the emergency department overall.
- On average, these children stayed in the ED 2.1 times longer than those with physical health issues.
- They also waited 1.6 times longer to be seen for their initial assessment by a doctor.
Over the five-year study period, the overall length of stay in the ED remained relatively unchanged. However, there was a slight improvement in how quickly children with mental health concerns were seen by a clinician — even though they were still waiting longer than their non-psychiatric peers.
Limitations
Despite the strength of using a large data set, the study had several limitations. It did not include any patient-reported outcomes, so it remains unclear how boarding in the emergency department impacted children’s well-being or their overall experience of care.
Seasonal variation — such as the return to school in September or pressure around the holiday period – was not considered, although these factors may influence rates of psychiatric presentations.
The study also didn’t take into account hospital discharge activity, which could affect bed availability and, in turn, influence how long children wait in the ED.
Lastly, children were grouped using diagnostic codes from the International Classification of Diseases (ICD), which may not always capture the complexity of presentations. This approach could lead to either underestimating or overestimating the number of children in each group.
CASP checklist for Cohort studies
Does this address a clearly focused issue?
Yes
Was the cohort recruited in an acceptable way?
Yes
Was the exposure accurately measured to minimize bias?
Yes
Was the outcome accurately measured to minimize bias?
Yes
Have the authors identified all-important confounding factors?
Yes, they acknowledge the limitations of the study design. These limitations prevented them from determining long-term patient outcomes in relation to boarding. Additional limitations with ICD-10 codes were correctly identified.
Was the follow-up of subjects complete and accurate?
There was no follow-up for patients in the study. This was mentioned as a limitation; however, the study’s objectives were not impacted.
What are the results?
During a five-year period, 38,821 patients were admitted to the ED, 25% for psychiatric concerns, and 75% for non-psychiatric concerns.
Psychiatric patients had 1.56 times longer boarding times than their non-psychiatric counterparts. Boarding times increased by 45% over five years for psychiatric patients compared to the boarding times experienced by non-psychiatric patients.
Do you believe the results?
Yes. The study employed a rigorous methodology and yielded similar findings to those of studies conducted in other countries.
Can the results be applied to a local population?
Yes
Do the results fit with other evidence available?
Yes
What did the authors conclude, and what does it mean for current practice?
Young people with mental health concerns are experiencing disproportionately longer waits for inpatient beds.
This means that changes to policies and resource allocation are required at multiple levels of the healthcare system to improve boarding times for pediatric patients. This study demonstrates that additional mental health beds, policy changes and additional interventions need to be explored to decrease the inequities that mental health patients are experiencing.
Take-home points
Children coming to the emergency department with mental health concerns experienced much longer boarding times.
The wait times for mental health patients to get assessed, leave the ED, or get a moved to an inpatient bed remained consistent or worsened over time.
More resources and policy changes are needed to solve the current inequities that exist for pediatric patients experiencing mental health concerns.
Effective changes to decrease overall ED boarding times for all patients will require a multi-pronged approach involving parties inside and outside of the ED.
References
Poonai N, Freedman SB, Newton AS, Sawyer S, Gaucher N, Ali S, et al. Emergency department visits and hospital admissions for suicidal ideation, self-poisoning and self-harm among adolescents in Canada during the COVID-19 pandemic. CMAJ [Internet]. 2023 [cited 2024 Aug 13];195:E1221–30. Available from: https://doi.org/10.1503/cmaj.220507
Rosic T, Duncan L, Wang L, Eltorki M, Boyle M, Sassi R, et al. Trends and Predictors of Repeat Mental Health Visits to a Pediatric Emergency Department in Hamilton, Ontario. Journal of the Canadian Academy of Child and Adolescent Psychiatry = Journal de l’Academie canadienne de psychiatrie de l’enfant et de l’adolescent [Internet]. 2019 [cited 2024 Aug 27]; Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6691794/
Pitts SR, Vaughns FL, Gautreau MA, Cogdell MW, Meisel Z. A Cross-sectional Study of Emergency Department Boarding Practices in the United States. Academic Emergency Medicine [Internet]. 2014 [cited 2024 Nov 2];21:497–503. Available from: https://doi.org/10.1111/acem.12375
Kappy B, Berkowitz D, Isbey S, Breslin K, McKinley K. Characteristics and patient impact of boarding in the pediatric emergency department, 2018–2022. The American Journal of Emergency Medicine [Internet]. 2024 [cited 2024 Aug 13];77:139–46. Available from: https://www.sciencedirect.com/science/article/pii/S0735675723007015
Doan Q, Genuis ED, Yu A. Trends in use in a Canadian pediatric emergency department. CJEM [Internet]. 2014;16:405–10. Available from: https://doi.org/10.2310/8000.2013.131280
Ibeziako P, Kaufman K, Scheer KN, Sideridis G. Pediatric Mental Health Presentations and Boarding: First Year of the COVID-19 Pandemic. Hospital Pediatrics [Internet]. 2022 [cited 2023 May 16];12:751–60. Available from: https://doi.org/10.1542/hpeds.2022-006555
Chisholm C, Wang X, Guild K, Lategan C, Hsu Z, Lang E. No room at the inn: pediatric psychiatric patients wait far longer for inpatient beds than their non-psychiatric counterparts; evidence of structural stigma. Can J Emerg Med [Internet]. 2025 [cited 2025 Aug 11]; Available from: https://link.springer.com/10.1007/s43678-025-00984-5
